Page 13 - Canadian Urological Association guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants (Full Version)

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Level 3 evidence putial retractibility and hygiene, rule out phimosis,
and counsel regarding HPV vaccination and safe
In a matched case control study, Tsen et al showed that sexual practices, as well as to offer the possibility
phimosis was a strong risk factor for invasive penile cancer of circumcision as a preventive measure against STIs
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(adjusted OR 16; 95% CI 4.5‒57). The protective effect of while specifying the drawbacks and efficacy of other
neonatal circumcision was not statistically significant when preventive measures (Grade D).
the analysis was restricted to those who did not have a his-
tory of phimosis (OR 0.79; 95% CI 0.29‒2.6) and smoking Circumcision and risk of prostate cancer
was a clear identified risk factor (OR 5.9 for >20 cigarettes/
day). In another population-based case control study from A meta-analysis of case control studies by Taylor et al found
Denmark, Madsen et al found that penile cancer was posi- an increased RR of prostate cancer in men with a history of
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tively associated with measures of high and early sexual STIs. A recent case control study explored the association
activity, genital warts, unprotected sex, and penile oral between circumcision and prostate cancer. In a multivari-
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sex. Phimosis (OR 4.9; 95% CI 1.85‒ 13.0), but not child- able analysis, controlling for age, family history, race, history
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hood circumcision (p=0.33) was also found to have a strong of STIs, number of partners, and history of prostatitis, the
association on multivariate analyses. The authors concluded authors did not find an overall association with circumci-
that an unretractable foreskin with HR HPV infection might sion (OR 0.87; 95% CI 0.74‒1.02). A previous case control
constitute the single most important risk factor for penile study from the U.K., looking primarily at dietary and sexual
cancer. In a population-based case control study by Daling history, found a borderline association on univariate analysis
et al, 137 men with penile cancer were compared with 671 between circumcision and prostate cancer risk (OR 0.62;
controls. Lack of childhood circumcision (OR 2.3; 95% CI 95% CI 0.39‒0.98). 143
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1.3‒4.1), phimosis (OR 7.4; 95% CI 3.7‒15.0), and cigarette Conclusion (MC and prostate cancer): There is no con-
smoking (OR 4.5; 95% CI 2.0‒10.1) were identified as risk vincing evidence on the protective effect of MC against
factors for invasive penile cancer, but after excluding patients prostate cancer (Level 3‒4, Grade B).
with phimosis, the analysis did not show a protective effect
of childhood circumcision. Role of the foreskin in sensation and sexual function

Level 2c evidence There is ongoing controversy regarding the impact of cir-
cumcision on penile sensitivity and sexual satisfaction. It is
Indirect evidence of the role of MC in preventing penile obvious that the foreskin has sensory nerves, which are lost
cancer can be investigated by ecological studies in countries following a circumcision. The primary question is whether
with low circumcision rates. Denmark, with 2% circum- this presumed loss of sensation or a possible decrease in
cision prevalence, showed decreasing and lower rates of glans sensitivity impacts sexual satisfaction in a measurable
penile cancer than in the U.S. However, in a more recent and consistent way after accounting for several confound-
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study from Denmark, there was an increase in the incidence ers. The timing of circumcision (adult vs. neonatal) may also
of penile cancer from 1 to 1.3 per 100 000 men-years impact this effect. The problem is amplified by the lack of
between 1978 and 2008. In the U.S., despite a decrease a single objective measure of sensitivity (sensation varying
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in circumcision rates, a 1.2% average annual incidence rate by type and site assessed, ejaculation latency, arousal). In
decrease has been noted between 1973 and 2003. 140 addition, this effect of MC has to be studied both from the
Recommendations (MC and penile cancer): men and their male and female partners’ perspective. It is
1. Circumcision decreases the risk of penile cancer hard to extrapolate results of adult MC studies on sexual
(Level 2‒3). function and sensation to neonatal circumcision.
2. However, given the low incidence of invasive penile
cancer, the partial protective effect of MC, and the Adult circumcision
availability of other preventive strategies, such as
HPV vaccination, condom use, and smoking ces- Level 1–2 evidence
sation programs, it is difficult to justify universal
neonatal circumcision as a preventive strategy for A recent meta-analysis included 10 studies with significant
preventing penile cancer (Grade B). heterogeneity and poor methodological quality to assess the
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3. Recognition and treatment of phimosis during regu- impact of MC on sexual function. There were no signifi-
lar health visits is recommended to decrease the risk cant differences in sexual desire, dyspareunia, premature
of penile cancer (Level 5, Grade D). A genitourinary ejaculation, ejaculation latency time, or erectile dysfunctions
exam during puberty is recommended to ensure pre- between circumcised and uncircumcised men. A secondary

E88 CUAJ • February 2018 • Volume 12, Issue 2